ACG: Refractory Bacteria Respond to Fecal Transplant

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Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Note that this multi-center study suggests that colonoscopic fecal microbiota transplant is rapidly effective as treatment for refractory C. difficile infection even in patients who were elderly, debilitated, and had undergone multiple failed courses of treatment.

WASHINGTON -- Transplanting fecal matter with healthy bacteria into patients with refractory Clostridium difficile infections can lead to quick relief, researchers said here.

Fecal microbiota transplant had a 91% rate of success -- defined as no recurrence within three months -- among 77 patients with refractory C. difficile infection, Mark Mellow, MD, of Integris Baptist Medical Center in Oklahoma City, and colleagues reported at the annual meeting of the American College of Gastroenterology.

The average time for resolution and improvement in diarrhea was six days; for fatigue, four weeks.

The success rate rose to 98% after six patients who failed the transplant procedure were given a two-week course of vancomycin -- alone or with probiotics -- or vancomycin plus an additional transplant.

"Patients with recurrent C. difficile infection had a totally different population in their stool than normal people, characterized by a marked decrease in the diversity of species present," Mellow said. "Therefore, it would make sense that if you performed a massive bacterial replacement, that might very well reverse that condition and allow for a cure in people who were otherwise not curable."

The positive results from this study are very likely to be practice changing, study co-author Lawrence Brandt, MD, emeritus chief of gastroenterology and liver diseases at Montefiore Medical Center in Bronx, N.Y., told MedPage Today.

"I think you're going to be seeing a change in the way gastroenterology is being practiced not only for C. difficile colitis but also for many other entities not only in the GI [gastrointestinal] tract, but also outside the GI tract, as a result of fecal transplantation," he said.

Patients with refractory C. difficile often have been through several courses of treatment; recurrence rates with the disorder are as high as 50%, the researchers noted. Prior studies have reported success with fecal transplants, but were limited to single centers.

To get a broader perspective, the investigators followed up with fecal transplant patients at five different U.S. medical centers. The 77 patients all answered a 36-item questionnaire about the results of the transplant.

Patients' mean age was 65 and 56 (73%) were women. The mean duration of illness was 11 months; 31 of the patients were hospitalized, homebound, or in a skilled nursing facility at the time the procedure was performed.

They had failed an average of five different medication courses prior to receiving the transplant, Mellow said during a press conference. All but one patient had at one point been on vancomycin, often with pulse/taper courses. Other medications tried before transplant included metronidazole, rifaximin, and probiotics.

Most of the donors of transplant material resided in the same household as the patient; only one patient did not have some sort of relationship with the donor.

Mean followup time post-transplant was 17 months, according to the investigators.

Two patients found that their preexisting conditions -- arthritis in one and sinus allergies in the other -- improved post-transplant, while four patients developed new disorders afterwards, including peripheral neuropathy, Sjogren's syndrome, rheumatoid arthritis, and idiopathic thrombocytopenia. One patient, who was in hospice care, died.

In response to a question at the press conference, Mellow said the patients did not seem to find the idea of a fecal transplant unpleasant. "They're desperate people seeking desperate measures so they didn't have much of a problem with it. We have to stop thinking of stool as a smelly inert substance; it's an incredibly biologically active substance."

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